Homeland Security and Emergency Management
A Division of the Minnesota Department of Public Safety
The purpose of the form is to collect, analyze and distribute information (sharing) between public and private sector partners.
Contact Information
Business Name
*
Contact Person
*
Phone Number
*
Email Address
*
Business Address
Street Address
*
Address Line 2
( Apt, Suite, Unit, etc. )
City
*
State
*
Zip Code
*
County
*
Business Operations
Which critical infrastructure sector do you represent?
*
-- Select infrastructure sector --
Chemical
Commercial Facilities
Communications
Critical Manufacturing
Dams
Defense Industrial Base
Emergency Services
Energy
Financial Services
Food and Agriculture
Government Facilities
Healthcare and Public Health
Information Technology
Nuclear Reactors, Materials, and Waste
Transportation Systems
Water and Wastewater Systems
Other
Are still you open for business?
*
Yes
No
Number of locations currently open?
*
Total Locations
*
Total number of employees working in Minnesota before COVID-19 incident
*
Total number of employees STILL working in Minnesota (include teleworking employees)
*
How have your operations changed?
*
-- Select Operational Changed --
Operations have increased
Operations have stayed the same
Operations have decreased
Operations have ceased
What is your projected enterprise impact if you have an employee test positive for COVID-19?
*
-- Select Imapact on Business --
Impacted not at all
Impacted slightly
Impacted moderately
Impacted greatly
I have Personal Protective Equipment (PPE) to donate.
*
Yes
No
I have resources to offer.
*
Yes
No
Explain resource(s) you have to offer.
Do you have any additional comments?